The diagnostic accuracy of neuromonitoring for detecting postoperative bowel and bladder dysfunction in spinal oncology surgery: a case series.

PURPOSE: Postoperative bowel and bladder dysfunction (BBD) poses a significant risk following surgery of the sacral spinal segments and sacral nerve roots, particularly in neuro-oncology cases. The need for more reliable neuromonitoring techniques to enhance the safety of spine surgery is evident. METHODS: We conducted a case series comprising 60 procedures involving 56 patients, spanning from September 2022 to January 2024. We assessed the diagnostic accuracy of sacral reflexes (bulbocavernosus and external urethral sphincter reflexes) and compared them with transcranial motor evoked potentials (TCMEP) incorporating anal sphincter (AS) and external urethral sphincter (EUS) recordings, as well as spontaneous electromyography (s-EMG) with AS and EUS recordings. RESULTS: Sacral reflexes demonstrated a specificity of 100% in predicting postoperative BBD, with a sensitivity of 73.33%. While sensitivity slightly decreased to 64.71% at the 1-month follow-up, it remained consistently high overall. TCMEP with AS/EUS recordings did not identify any instances of postoperative BBD, whereas s-EMG with AS/EUS recordings showed a sensitivity of 14.29% and a specificity of 97.14%. CONCLUSION: Sacral reflex monitoring emerges as a robust adjunct to routine neuromonitoring, offering surgeons valuable predictive insights to potentially mitigate the occurrence of postoperative BBD.

Enhancing Diagnostic Support for Chiari Malformation and Syringomyelia: A Comparative Study of Contextualized ChatGPT Models.

OBJECTIVES: The rapidly increasing adoption of large language models in medicine has drawn attention to potential applications within the field of neurosurgery. This study evaluates the effects of various contextualization methods on ChatGPT's ability to provide expert-consensus aligned recommendations on the diagnosis and management of Chiari Malformation and Syringomyelia. METHODS: Native GPT4 and GPT4 models contextualized using various strategies were asked questions revised from the 2022 Chiari and Syringomyelia Consortium International Consensus Document. ChatGPT-provided responses were then compared to consensus statements using reviewer assessments of 1) responding to the prompt, 2) agreement of ChatGPT response with consensus statements, 3) recommendation to consult with a medical professional, and 4) presence of supplementary information. Flesch-Kincaid, SMOG, word count, and Gunning-Fog readability scores were calculated for each model using the quanteda package in R. RESULTS: Relative to GPT4, all contextualized GPTs demonstrated increased agreement with consensus statements. PDF+Prompting and Prompting models provided the most elevated agreement scores of 19 of 24 and 23 of 24, respectively, versus 9 of 24 for GPT4 (p=.021, p=.001). A trend toward improved readability was observed when comparing contextualized models at large to ChatGPT4, with significant decreases in average word count (180.7 vs 382.3, p<.001) and Flesch-Kincaid Reading Ease score (11.7 vs 17.2, p=.033). CONCLUSIONS: The enhanced performance observed in response to ChatGPT4 contextualization suggests broader applications of large language models in neurosurgery than what the current literature indicates. This study provides proof of concept for the use of contextualized GPT models in neurosurgical contexts and showcases the easy accessibility of improved model performance.

A comparison of transforaminal lumbar interbody fusion (TLIF) cage material on fusion rates: A systematic review and network meta-analysis.

Background: A wide variety of materials are used for lumbar interbody fusion, but there is no unified consensus on the superiority of one material over another. The aim of this systematic review and network meta-analysis (NMA) is to compare and rank the various TLIF interbody materials based on fusion rates. Methods: We queried PubMed, EMBASE and Scopus from inception until August 2023, in which 2135 studies were identified. Inclusion criteria were applied based on the PRISMA guidelines. The fusion assessment employed the Bridwell's criteria with a length of follow-up of at least 12 months. The NMA was conducted to compare multiple approaches from multiple studies using the frequentist framework with STATA16. Results: In total, 13 TLIF studies involving 1919 patients with 1981 lumbar interbody levels fulfilled our eligibility criteria. Seven different cage materials were utilized: polyetheretherketone (PEEK, as the reference), allograft, autograft, PEEK with titanium coating (TiPEEK), titanium, carbon/carbon fiber reinforced polymer (CFRP) and 3D-printed titanium. The average patient age was 60.9 (SD = 7.5) years old. When compared to PEEK, the other six materials did not have a significantly different rate of lumbar fusion. However, the SUCRA number of the 3D-printed titanium, TiPEEK, Ti, allograft, autograft, CFRP, and PEEK were 0.8, 0.6, 0.5, 0.5, 0.4, 0.4, and 0.3 consecutively. Conclusions: Based on a network meta-analysis within the confines of our clinical study, 3D-printed titanium interbody cage may promote the highest success rate of fusion while PEEK may be the material with the least success rate of fusion in TLIF.

A Bibliometric Analysis of the 20 Most Cited Articles on Sacrococcygeal Chordomas.

This study aims to summarize sacrococcygeal chordoma literature through bibliometric analysis and to offer insights into key studies to guide clinical practices and future research. The Web of Science database was searched using the terms "sacral chordoma", "chordomas of the sacrum", "chordomas of the sacral spine", "chordomas of the sacrococcygeal region", "coccygeal chordoma", and "coccyx chordoma". Articles were analyzed for citation count, authorship, publication date, journal, research area tags, impact factor, and evidence level. The median number of citations was 75 (range: 53-306). The primary publication venue was the International Journal of Radiation Oncology, Biology, Physics. Most works, published between 1999 and 2019, featured a median journal impact factor of 3.8 (range: 2.1-7) and predominantly fell under the research area tag, radiation, nuclear medicine, and imaging. Of these articles, 19 provided clinical data with predominantly level III evidence, and one was a literature review. This review highlights the increasing volume of sacrococcygeal chordoma publications over the past two decades, indicating evolving treatment methods and interdisciplinary patient care. Advances in radiation, particularly intensity-modulated radiation therapy (IMRT) and proton beam therapy, are believed to be propelling research growth, and the lack of level I evidence underscores the need for more rigorous studies to refine treatment protocols for sacrococcygeal chordomas.

Direct (D)-Wave Monitoring Enhancement With Subdural Electrode Placement: A Case Series.

PURPOSE: Direct-wave (D-wave) neuromonitoring is a direct measure of corticospinal tract integrity that detects potential injury during spinal cord surgery. Epidural placement of electrodes used for D-wave measurements can result in high electrical impedances resulting in substantial signal noise that can compromise signal interpretation. Subdural electrode placement may offer a solution. METHODS: Medical records for consecutive patients with epidural and subdural D-wave monitoring were reviewed. Demographic and clinical information including preoperative and postoperative motor strength were recorded. Neuromonitoring charts were reviewed to characterize impedances and signal amplitudes of D-waves recorded epidurally (before durotomy) and subdurally (following durotomy). Nonparametric statistics were used to compare epidural and subdural D-waves. RESULTS: Ten patients (50% women, median age 50.5 years) were analyzed, of which five patients (50%) were functionally independent (modified McCormick grade ≤ II) preoperatively. D-waves were successfully acquired by subdural electrodes in eight cases and by epidural electrodes in three cases. Subdural electrode placement was associated with lower impedance values ( P = 0.011) and a higher baseline D-wave amplitude ( P = 0.007) relative to epidural placement. No association was observed between D-wave obtainability and functional status, and no adverse events relating to subdural electrode placement were encountered. CONCLUSIONS: Subdural electrode placement allows successful D-wave acquisition with accurate monitoring, clearer waveforms, and a more optimal signal-to-noise ratio relative to epidural placement. For spinal surgeries where access to the subdural compartment is technically safe and feasible, surgeons should consider subdural placement when monitoring D-waves to optimize clinical interpretation.

Association of Malnutrition with Surgical and Hospital Outcomes after Spine Surgery for Spinal Metastases: A National Surgical Quality Improvement Program Study of 1613 Patients.

Background: Malnutrition is a common condition that may exacerbate many medical and surgical pathologies. However, few have studied the impact of malnutrition on surgical outcomes for patients undergoing surgery for metastatic disease of the spine. This study aims to evaluate the impact of malnutrition on perioperative complications and healthcare resource utilization following surgical treatment of spinal metastases. Methods: We conducted a retrospective cohort study using the 2011-2019 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients with spinal metastases who underwent laminectomy, corpectomy, or posterior fusion for extradural spinal metastases were identified using the CPT, ICD-9-CM, and ICD-10-CM codes. The study population was divided into two cohorts: Nourished (preoperative serum albumin values ≥ 3.5 g/dL) and Malnourished (preoperative serum albumin values < 3.5 g/dL). We assessed patient demographics, comorbidities, intraoperative variables, postoperative adverse events (AEs), hospital LOS, discharge disposition, readmission, and reoperation. Multivariate logistic regression analyses were performed to identify the factors associated with a prolonged length of stay (LOS), AEs, non-routine discharge (NRD), and unplanned readmission. Results: Of the 1613 patients identified, 26.0% were Malnourished. Compared to Nourished patients, Malnourished patients were significantly more likely to be African American and have a lower BMI, but the age and sex were similar between the cohorts. The baseline comorbidity burden was significantly higher in the Malnourished cohort compared to the Nourished cohort. Compared to Nourished patients, Malnourished patients experienced significantly higher rates of one or more AEs (Nourished: 19.8% vs. Malnourished: 27.6%, p = 0.004) and serious AEs (Nourished: 15.2% vs. Malnourished: 22.6%, p < 0.001). Upon multivariate regression analysis, malnutrition was found to be an independent and associated with an extended LOS [aRR: 3.49, CI (1.97, 5.02), p < 0.001], NRD [saturated aOR: 1.76, CI (1.34, 2.32), p < 0.001], and unplanned readmission [saturated aOR: 1.42, CI (1.04, 1.95), p = 0.028]. Conclusions: Our study suggests that malnutrition increases the risk of postoperative complication, prolonged hospitalizations, non-routine discharges, and unplanned hospital readmissions. Further studies are necessary to identify the protocols that pre- and postoperatively optimize malnourished patients undergoing spinal surgery for metastatic spinal disease.

Oncologic and Functional Outcomes After Stereotactic Body Radiation Therapy for High-Grade Malignant Spinal Cord Compression.

Purpose: Although surgical decompression is the gold standard for metastatic epidural spinal cord compression (MESCC) from solid tumors, not all patients are candidates or undergo successful surgical Bilsky downgrading. We report oncologic and functional outcomes for patients treated with stereotactic body radiation therapy (SBRT) to high-grade MESCC. Methods and Materials: Patients with Bilsky grade 2 to 3 MESCC from solid tumor metastases treated with SBRT at a single institution from 2009 to 2020 were retrospectively reviewed. Patients who received upfront surgery before SBRT were included only if postsurgical Bilsky grade remained ≥2. Neurologic examinations, magnetic resonance imaging, pain assessments, and analgesic usage were assessed every 3 to 4 months post-SBRT. Cumulative incidence of local recurrence was calculated with death as a competing risk, and overall survival was estimated by Kaplan-Meier. Results: One hundred forty-three patients were included. The cumulative incidence of local recurrence was 5.1%, 7.5%, and 14.1% at 6, 12, and 24 months, respectively. At first post-SBRT imaging, 16.2% of patients with initial Bilsky grade 2 improved to grade 1, and 53.8% of patients were stable. Five of 13 patients (38.4%) with initial Bilsky grade 3 improved to grade 1 to 2. Pain response at 3 and 6 months post-SBRT was complete in 45.4% and 55.7%, partial in 26.9% and 13.1%, stable in 24.1% and 27.9%, and worse in 3.7% and 3.3% of patients, respectively. At 3 and 6 months after SBRT, 17.8% and 25.0% of patients had improved ambulatory status and 79.7% and 72.4% had stable status. Conclusions: We report the largest series to date of patients with high-grade MESCC treated with SBRT. The excellent local control and functional outcomes suggest SBRT is a reasonable approach in inoperable patients or cases unable to be successfully surgically downgraded.

Racial disparities in the management and outcomes of primary osseous neoplasms of the spine: a SEER analysis.

PURPOSE: Primary osseous neoplasms of the spine, including Ewing's sarcoma, osteosarcoma, chondrosarcoma, and chordoma, are rare tumors with significant morbidity and mortality. The present study aims to identify the prevalence and impact of racial disparities on management and outcomes of patients with these malignancies. METHODS: The 2000 to 2020 Surveillance, Epidemiology, and End Results (SEER) Registry, a cancer registry, was retrospectively reviewed to identify patients with Ewing's sarcoma, osteosarcoma, chondrosarcoma, or chordoma of the vertebral column or sacrum/pelvis. Study patients were divided into race-based cohorts: White, Black, Hispanic, and Other. Demographics, tumor characteristics, treatment variables, and mortality were assessed. RESULTS: 2,415 patients were identified, of which 69.8% were White, 5.8% Black, 16.1% Hispanic, and 8.4% classified as "Other". Tumor type varied significantly between cohorts, with osteosarcoma affecting a greater proportion of Black patients compared to the others (p < 0.001). A lower proportion of Black and Other race patients received surgery compared to White and Hispanic patients (p < 0.001). Utilization of chemotherapy was highest in the Hispanic cohort (p < 0.001), though use of radiotherapy was similar across cohorts (p = 0.123). Five-year survival (p < 0.001) and median survival were greatest in White patients (p < 0.001). Compared to non-Hispanic Whites, Hispanic (p < 0.001) and "Other" patients (p < 0.001) were associated with reduced survival. CONCLUSION: Race may be associated with tumor characteristics at diagnosis (including subtype, size, and site), treatment utilization, and mortality, with non-White patients having lower survival compared to White patients. Further studies are necessary to identify underlying causes of these disparities and solutions for eliminating them.

Association Between Urbanicity and Outcomes Among Patients with Spinal Cord Ependymomas in the United States.

BACKGROUND: Spinal cord ependymomas (SCEs) represent the most common intramedullary spinal cord tumors among adults. Research shows that access to neurosurgical care and patient outcomes can be greatly influenced by patient location. This study investigates the association between the outcomes of patients with SCE in metropolitan and nonmetropolitan areas. METHODS: Cases of SCE between 2004 and 2019 were identified within the Central Brain Tumor Registry of the United States, a combined dataset including the Centers for Disease Control and Prevention's National Program of Cancer Registries and National Cancer Institute's Surveillance, Epidemiology, and End Results Program data. Multivariable logistic regression models were constructed to evaluate the association between urbanicity and SCE treatment, adjusted for age at diagnosis, sex, race and ethnicity. Survival data was available from 42 National Program of Cancer Registries (excluding Kansas and Minnesota, for which county data are unavailable), and Cox proportional hazard models were used to understand the effect of surgical treatment, county urbanicity, age at diagnosis, and the interaction effect between age at diagnosis and surgery, on the survival time of patients. RESULTS: Overall, 7577 patients were identified, with 6454 (85%) residing in metropolitan and 1223 (15%) in nonmetropolitan counties. Metropolitan and nonmetropolitan counties had different age, sex, and race/ethnicity compositions; however, demographics were not associated with differences in the type of surgery received when stratified by urbanicity. Irrespective of metropolitan status, individuals who were American Indian/Alaska Native non-Hispanic and Hispanic (all races) were associated with reduced odds of receiving surgery. Individuals who were Black non-Hispanic and Hispanic were associated with increased odds of receiving comprehensive treatment. Diagnosis of SCE at later ages was linked with elevated mortality (hazard ratio = 4.85, P < 0.001). Gross total resection was associated with reduced risk of death (hazard ratio = 0.37, P = 0.004), and age did not interact with gross total resection to influence risk of death. CONCLUSIONS: The relationship between patients' residential location and access to neurosurgical care is critical to ensuring equitable distribution of care. This study represents an important step in delineating areas of existing disparities.

Implications of Frailty on Postoperative Health Care Resource Utilization in Ankylosing Spondylitis Patients Undergoing Spine Surgery for Spinal Fractures.

OBJECTIVE: The rise of spinal surgery for ankylosing spondylitis (AS) necessitates balancing health care costs with quality patient care. Frailty has been independently associated with adverse outcomes and increased costs. This study investigates whether frailty is an independent predictor of poor outcomes after elective surgery for AS. METHODS: Using the National Inpatient Sample (NIS) database, a retrospective study was conducted on adult patients with AS who underwent posterior spinal fusion for fracture between 2016 and 2019. Each patient was assigned a modified frailty index (mFI) score and categorized as prefrail (mFI = 0 or 1), moderately frail (mFI = 2), and highly frail (mFI≥3). Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay, non-routine discharge (NRD), and exorbitant admission costs. RESULTS: Of the 1910 patients, 35.3% were prefrail, 31.2% moderately frail, and 33.5% highly frail. Age was significantly different across groups (P < 0.001), and frailty was associated with increased comorbidities (P < 0.001). Mean length of stay (P = 0.007), NRD rate (P < 0.001), and mean cost of admission (P = 0.002) all significantly increased with increasing frailty. However, frailty was not an independent predictor of extended hospital stay, NRD, or higher costs on multivariate analysis. Instead, predictors included multiple adverse events, number of comorbidities, and race. CONCLUSIONS: While frailty in patients with AS is associated with older age, greater comorbidities, and increased adverse events, it was not an independent predictor of extended hospital stay, NRD, or higher hospital costs. Further research is required to understand the full impact of frailty on surgical outcomes and develop effective interventions.

Treatment of intramedullary spinal cord tumors: a modified Delphi technique of the North American Spine Society Section of Spine Oncology.

OBJECTIVE: Intramedullary spinal cord tumors (IMSCTs) are rare tumors with heterogeneous presentations and natural histories that complicate their management. Standardized guidelines are lacking on when to surgically intervene and the appropriate aggressiveness of resection, especially given the risk of new neurological deficits following resection of infiltrative tumors. Here, the authors present the results of a modified Delphi method using input from surgeons experienced with IMSCT removal to construct a framework for the operative management of IMSCTs based on the clinical, radiographic, and tumor-specific characteristics. METHODS: A modified Delphi technique was conducted using a group of 14 neurosurgeons experienced in IMSCT resection. Three rounds of written correspondence, surveys, and videoconferencing were carried out. Participants were queried about clinical and radiographic criteria used to determine operative candidacy and guide decision-making. Members then completed a final survey indicating their choice of observation or surgery, choice of resection strategy, and decision to perform duraplasty, in response to a set of patient- and tumor-specific characteristics. Consensus was defined as ≥ 80% agreement, while responses with 70%-79% agreement were defined as agreement. RESULTS: Thirty-six total characteristics were assessed. There was consensus favoring surgical intervention for patients with new-onset myelopathy (86% agreement), chronic myelopathy (86%), or progression from mild to disabling numbness (86%), but disagreement for patients with mild numbness or chronic paraplegia. Age was not a determinant of operative candidacy except among frail patients, who were deemed more suitable for observation (93%). Well-circumscribed (93%) or posteriorly located tumors reaching the surface (86%) were consensus surgical lesions, and participants agreed that the presence of syringomyelia (71%) and peritumoral T2 signal change (79%) were favorable indications for surgery. There was consensus that complete loss of transcranial motor evoked potentials with a 50% decrease in the D-wave amplitude should halt further resection (93%). Preoperative symptoms seldom influenced choice of resection strategy, while a distinct cleavage plane (100%) or visible tumor-cord margins (100%) strongly favored gross-total resection. CONCLUSIONS: The authors present a modified Delphi technique highlighting areas of consensus and agreement regarding surgical management of IMSCTs. Although not intended as a substitute for individual clinical decision-making, the results can help guide care of these patients. Additionally, areas of controversy meriting further investigation are highlighted.

Racial/Ethnic Disparities Among Patients Undergoing Anterior Cervical Discectomy and Fusion or Posterior Cervical Decompression and Fusion for Cervical Spondylotic Myelopathy: A National Administrative Database Analysis.

INTRODUCTION: The aim of this study was to investigate the impact of racial disparities on surgical outcomes for cervical spondylotic myelopathy (CSM). METHODS: Adult patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) for CSM were identified from the 2016 to 019 National Inpatient Sample Database using the International Classification of Diseases codes. Patients were categorized based on approach (ACDF or PCDF) and race/ethnicity (White, Black, Hispanic). Patient demographics, comorbidities, operative characteristics, adverse events, and health care resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS), nonroutine discharge (NRD), and exorbitant costs. RESULTS: A total of 46,500 patients were identified, of which 36,015 (77.5%) were White, 7465 (16.0%) were Black, and 3020 (6.5%) were Hispanic. Black and Hispanic patients had a greater comorbidity burden compared to White patients (P = 0.001) and a greater incidence of any postoperative complication (P = 0.001). Healthcare resource utilization were greater in the PCDF cohort than the ACDF cohort and greater in Black and Hispanic patients compared to White patients (P < 0.001). Black and Hispanic patient race were significantly associated with extended hospital LOS ([Black] odds ratio [OR]: 2.24, P < 0.001; [Hispanic] OR: 1.64, P < 0.001) and NRD ([Black] OR: 2.33, P < 0.001; [Hispanic] OR: 1.49, P = 0.016). Among patients who underwent PCDF, Black race was independently associated with extended hospital LOS ([Black] OR: 1.77, P < 0.001; [Hispanic] OR: 1.47, P = 0.167) and NRD ([Black] OR: 1.82, P < 0.001; [Hispanic] OR: 1.38, P = 0.052). CONCLUSIONS: Our study suggests that patient race may influence patient outcomes and healthcare resource utilization following ACDF or PCDF for CSM.

Intraoperative Monitoring of the External Urethral Sphincter Reflex: A Novel Adjunct to Bulbocavernosus Reflex Neuromonitoring for Protecting the Sacral Neural Pathways Responsible for Urination, Defecation and Sexual Function.

PURPOSE: Intraoperative bulbocavernosus reflex neuromonitoring has been utilized to protect bowel, bladder, and sexual function, providing a continuous functional assessment of the somatic sacral nervous system during surgeries where it is at risk. Bulbocavernosus reflex data may also provide additional functional insight, including an evaluation for spinal shock, distinguishing upper versus lower motor neuron injury (conus vs. cauda syndromes) and prognosis for postoperative bowel and bladder function. Continuous intraoperative bulbocavernosus reflex monitoring has been utilized to provide the surgeon with an ongoing functional assessment of the anatomical elements involved in the S2-S4 mediated reflex arc including the conus, cauda equina and pudendal nerves. Intraoperative bulbocavernosus reflex monitoring typically includes the electrical activation of the dorsal nerves of the genitals to initiate the afferent component of the reflex, followed by recording the resulting muscle response using needle electromyography recordings from the external anal sphincter. METHODS: Herein we describe a complementary and novel technique that includes recording electromyography responses from the external urethral sphincter to monitor the external urethral sphincter reflex. Specialized foley catheters embedded with recording electrodes have recently become commercially available that provide the ability to perform intraoperative external urethral sphincter muscle recordings. RESULTS: We describe technical details and the potential utility of incorporating external urethral sphincter reflex recordings into existing sacral neuromonitoring paradigms to provide redundant yet complementary data streams. CONCLUSIONS: We present two illustrative neurosurgical oncology cases to demonstrate the utility of the external urethral sphincter reflex technique in the setting of the necessary surgical sacrifice of sacral nerve roots.

Extreme lateral infracondylar approach for internal jugular vein compression syndrome: A case series with preliminary clinical outcomes.

BACKGROUND AND OBJECTIVES: Internal jugular vein (IJV) stenosis is associated with several neurological disorders including idiopathic intracranial hypertension (IIH) and pulsatile tinnitus. In cases of extreme bony compression causing stenosis in the infracondylar region, surgical decompression might be necessary. We aim to examine the safety and efficacy of surgical IJV decompression. METHODS: We retrospectively reviewed patients who received surgical IJV decompression via the extreme lateral infracondylar (ELI) approach between July 2020 and February 2022. RESULTS: Fourteen patients with IJV stenosis were identified, all with persistent headache and/or tinnitus. Six patients were diagnosed with IIH, three of whom failed previous treatment. Of the eight remaining patients, two failed previous treatment. All underwent surgical IJV decompression via styloidectomy, release of soft tissue, and removal of the C1 transverse process (TP). Follow-up imaging showed significant improvement of IJV stenosis in eleven patients and mild improvement in three. Eight patients had significant improvement in their presenting symptoms, and three had partial improvement. Two patients received IJV stenting after a lack of initial improvement. Two patients experienced cranial nerve paresis, and one developed a superficial wound infection. CONCLUSION: The ELI approach for IJV decompression appears to be safe for patients who are not ideal endovascular candidates due to bony anatomy. Confirming long-term efficacy in relieving debilitating clinical symptoms requires longer follow-up and a larger patient cohort. Carefully selected patients with symptomatic bony IJV compression for whom there are no effective medical or endovascular options may benefit from surgical IJV decompression.

Novel Standalone Motion-Sparing Pelvic Fixation Prevents Short-Term Insufficiency Fractures After Midsacrectomies Without Sacrificing Normal, Mobile Lumbar Segments Traditionally Used for Stabilization.

BACKGROUND AND OBJECTIVES: Sacrectomy is often the treatment of choice to provide the greatest chance of progression-free and overall survival for patients with primary malignant bone tumors of the sacrum. After midsacrectomy, the stability of the sacropelvic interface is diminished, resulting in insufficiency fractures. Traditional stabilization involves lumbopelvic fixation but subjects normal mobile segments to fusion. The purpose of this study was to determine whether standalone intrapelvic fixation is a safe adjunct to midsacrectomy, avoiding both sacral insufficiency fractures and the morbidity of instrumenting into the mobile spine. METHODS: A retrospective study identified all patients who underwent resection of sacral tumors at 2 comprehensive cancer centers between June 2020 and July 2022. Demographic, tumor-specific, operative characteristics and outcome data were collected. The primary outcome was presence of sacral insufficiency fractures. A retrospective data set of patients undergoing midsacrectomy without hardware placement was collected as a control. RESULTS: Nine patients (5 male, 4 female), median age 59 years, underwent midsacrectomy with concomitant placement of standalone pelvic fixation. No patients developed insufficiency fractures during the 216 days of clinical and 207 days of radiographic follow-up. There were no adverse events attributable to the addition of standalone pelvic fixation. In our historical cohort of partial sacrectomies without stabilization, there were 4/25 patients (16%) with sacral insufficiency fractures. These fractures appeared between 0 and 5 months postoperatively. CONCLUSION: A novel standalone intrapelvic fixation after partial sacrectomy is a safe adjunct to prevent postoperative sacral insufficiency fractures in patients undergoing midsacrectomy for tumor. Such a technique may allow for long-term sacropelvic stability without sacrificing mobile lumbar segments.

Radiotherapy for Mobile Spine and Sacral Chordoma: A Critical Review and Practical Guide from the Spine Tumor Academy.

Chordomas are rare tumors of the embryologic spinal cord remnant. They are locally aggressive and typically managed with surgery and either adjuvant or neoadjuvant radiation therapy. However, there is great variability in practice patterns including radiation type and fractionation regimen, and limited high-level data to drive decision making. The purpose of this manuscript was to summarize the current literature specific to radiotherapy in the management of spine and sacral chordoma and to provide practice recommendations on behalf of the Spine Tumor Academy. A systematic review of the literature was performed using the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) approach. Medline and Embase databases were utilized. The primary outcome measure was the rate of local control. A detailed review and interpretation of eligible studies is provided in the manuscript tables and text. Recommendations were defined as follows: (1) consensus: approved by >75% of experts; (2) predominant: approved by >50% of experts; (3) controversial: not approved by a majority of experts. Expert consensus supports dose escalation as critical in optimizing local control following radiation therapy for chordoma. In addition, comprehensive target volumes including sites of potential microscopic involvement improve local control compared with focal targets. Level I and high-quality multi-institutional data comparing treatment modalities, sequencing of radiation and surgery, and dose/fractionation schedules are needed to optimize patient outcomes in this locally aggressive malignancy.

Socioeconomic and Racial/Ethnic Disparities in Perception of Health Status and Literacy in Spine Oncological Patients: Insights from the All of Us Research Program.

STUDY DESIGN: A cross-sectional study was performed using the National Institutes of Health All of Us survey database. OBJECTIVE: The aim of this study was to assess socioeconomic and racial disparities in the perception of personal health, health literacy, and healthcare access among spine oncology patients. SUMMARY OF BACKGROUND DATA: Racial, ethnic, and socioeconomic disparities in health literacy and perception of health status have been described for many disease processes. However, few studies have assessed the prevalence of these disparities among spine oncology patients. METHODS: Adult spine oncology patients, identified using ICD-9/10-CM codes, were categorized by race/ethnicity: White/Caucasian (WC), Black/African-American (BAA), and Non-White Hispanic (NWH). Demographics and socioeconomic status were assessed. Questionnaire responses regarding baseline health status, perception of health status, health literacy, and barriers to healthcare were compared. RESULTS: Of the 1,175 patients identified, 207 (17.6%) were BAA, 267 (22.7%) were NWH, and 701 (59.7%) were WC. Socioeconomic status varied among cohorts, with WC patients reporting higher levels of education ( P<0.001 ), annual income greater than $50K ( P<0.001 ), and home ownership ( P<0.001 ). BAA and NWH patients reported greater rates of 7-day "Severe fatigue" ( P<0.001 ) and "10/10 pain" ( P<0.001 ) and lower rates of "Completely" able to perform everyday activities ( P<0.001 ). WC patients had a higher response rate for "Excellent/Very Good" regarding their own general health ( P<0.001 ) and quality ( P<0.001 ). The WC cohort had a significantly higher proportion of patients responding "Never" when assessing difficulty understanding ( P<0.001 ) and needing assistance with health materials ( P<0.001 ). BAA and NWH were significantly less likely to report feeling "Extremely" confident with medical forms ( P<0.001 ). BAA and NWH had significantly higher response rates to feeling "Somewhat Worried" about healthcare costs ( P<0.001 ) and with delaying medical care given "Can't Afford Co-pay" ( P<0.001 ). CONCLUSION: We identified disparities in perception of health status, literacy, and access among spine oncology patients. LEVEL OF EVIDENCE: 4.

Safety and clinical efficacy of immune checkpoint inhibition and stereotactic body radiotherapy in patients with spine metastasis.

OBJECTIVE: Immunotherapy, particularly immune checkpoint inhibitors (ICIs), has revolutionized the treatment of patients with many tumor histologies. Simultaneously, stereotactic body radiotherapy (SBRT) provides excellent local control (LC) and plays an important role in the management of spine metastasis. Promising preclinical work suggests the potential therapeutic benefit of combining SBRT with ICI therapy, but the safety profile of combined therapy is unclear. This study aimed to evaluate the toxicity profile associated with ICI in patients receiving SBRT and, secondarily, whether ICI administration sequence with respect to SBRT affects LC or overall survival (OS) outcomes. METHODS: The authors retrospectively reviewed patients with spine metastasis treated with SBRT at an academic center. Patients who received ICI at any point during their disease course were compared to those with the same primary tumor types who did not receive ICI by using Cox proportional hazards analyses. Primary outcomes were long-term sequelae, including radiation-induced spinal cord myelopathy, esophageal stricture, and bowel obstruction. Secondarily, models were created to evaluate OS and LC in the cohort. RESULTS: Two hundred forty patients who received SBRT to 299 spine metastases were included in this study. The most common primary tumor types were non-small cell lung cancer (n = 59 [24.6%]) and renal cell carcinoma (n = 55 [22.9%]). One hundred eight patients received at least 1 dose of ICI, with the most common regimen being single-agent anti-PD-1 (n = 80 [74.1%]), followed by combination CTLA-4/PD-1 inhibitors (n = 19 [17.6%]). Three patients experienced long-term radiation-induced sequelae: 2 had esophageal stricture and 1 had bowel obstruction. No patients developed radiation-induced myelopathy. There was no association between receipt of ICI and development of any of these adverse events (p > 0.9). Similarly, ICI was not significantly associated with either LC (p = 0.3) or OS (p = 0.6). In the entire cohort, patients who received ICI prior to beginning SBRT had worse median survival, but ICI sequence with respect to SBRT was not significantly prognostic of either LC (p > 0.3) or OS (p > 0.07); instead, baseline performance status was most predictive of OS (HR 1.38, 95% CI 1.07-1.78, p = 0.012). CONCLUSIONS: Treatment regimens that combine ICIs before, concurrent with, and after SBRT for spine metastases are safe, with minimal risk for increased rates of long-term toxicity.

The Ribbon Sign as a Radiological Indicator of Intramedullary Spinal Cord Subependymomas.

OBJECTIVE: Intramedullary spinal cord (IMSC) subependymomas are rare World Health Organization grade 1 ependymal tumors. The potential presence of functional neural tissue within the tumor and poorly demarcated planes presents a risk to resection. Anticipating a subependymoma on preoperative imaging can inform surgical decision-making and improve patient counseling. Here, we present our experience recognizing IMSC subependymomas on preoperative magnetic resonance imaging (MRI) based on a distinctive characteristic termed the "ribbon sign." METHODS: We retrospectively reviewed preoperative MRIs of patients presenting with IMSC tumors at a large tertiary academic institution between April 2005 and January 2022. The diagnosis was confirmed histologically. The "ribbon sign" was defined as a ribbon-like structure of T2 isointense spinal cord tissue interwoven between regions of T2 hyperintense tumor. The ribbon sign was confirmed by an expert neuroradiologist. RESULTS: MRIs from 151 patients were reviewed, including 10 patients with IMSC subependymomas. The ribbon sign was demonstrated on 9 (90%) patients with histologically proven subependymomas. Other tumor types did not display the ribbon sign. CONCLUSION: The ribbon sign is a potentially distinctive imaging feature of IMSC subependymomas and indicates the presence of spinal cord tissue between eccentrically located tumors. Recognition of the ribbon sign should prompt clinicians to consider a diagnosis of subependymoma, aiding the neurosurgeon in planning the surgical approach and adjusting the surgical outcome expectation. Consequently, the risks and benefits of gross-versus subtotal resection for palliative debulking should be carefully considered and discussed with patients.